The dx I came up with are : T81.42XD L03.311 and then dx codes for the infection which I will have to have the provider add to the documentation. Would A49.8 and A49.02 be correct for the infection?
Pt presents for F/U ABD wound. Pt s/p tummy tuck 4/28/2021 tummy tuck in Dominican Republic. Pt reports Abd incision is open and drainage has improved. Pt has a video appt. with me 5/26/2021 and explained she moved to Orlando, FL and going to an ER in Orlando, FL for suture removal and wound evaluation. Pt explained she she went to Orlando ER and informed wound is healing well and have PCP remove sutures. Pt missed 5/24/2021 suture removal appt. with me to remove wounds. Pt sutures overdue for removal, Pt reports Dominican Plastic surgeon informed her sutures can be removed in 1month, no post op instructions forms at visit.
Pt referred and wound care and 5/28/2021 Pt demographics sent to Morton Plant Hosp, pt. awaiting wound appt.
Test: Anaerobic and Aerobic Culture Report Date: 05/25/2021
Anaerobic Culture Final report
Aerobic Culture Final report Abnormal
Result 1 Comment Abnormal
Result 2 Escherichia coli Abnormal
Antimicrobial Susceptibility Comment
Result 1 Comment
Wound culture +Staph and+ Coli. Pt informed she will need to Complete Doxy and then start Augmentin. Pt currently not on any hormone contraception. Pt denies she is having sexual intercourse and in office urine preg neg.
Exam
Skin:
• Showed erythema large lower abd incision with multiple open areas no drainage, improved since last visit
Umbilicus with multiple suture and right abd with suture x 1 intact edges well approx. right lower abd suture x1 removed, umbilical sutures removed x 2. Remaining 3 sutures with skin growing over suture and unable to remove remaining sutures. ° General appearance was normal.
ASSESSMENT
Open wound of the anterior abdominal wall
PLAN
• Unsp open Wound abd wall, Unsp q w/o penet perit cav, sequela
In House Labs: Pregnancy Test Urine
Amoxicillin-Pot Clavulanate 875-125 MG tablet 1 tab PO twice a day x 10 days. Take with food. START AFTER COMPLETING DOXYCYCLINE., 10 days, 0 refills
Pt informed she need back up birth control method to prevent pregnancy such as condoms
Pt informed she needs to contact surgeon regarding f/U for suture removal instructions, pt approved for wound care which may be able to remove remaining sutrues if surgeon unable to provide further F/U for pt.
complete Doxycycline as prescribed, and THEN start Augmentin
F/U in 2 weeks to re-check wound
Pt presents for F/U ABD wound. Pt s/p tummy tuck 4/28/2021 tummy tuck in Dominican Republic. Pt reports Abd incision is open and drainage has improved. Pt has a video appt. with me 5/26/2021 and explained she moved to Orlando, FL and going to an ER in Orlando, FL for suture removal and wound evaluation. Pt explained she she went to Orlando ER and informed wound is healing well and have PCP remove sutures. Pt missed 5/24/2021 suture removal appt. with me to remove wounds. Pt sutures overdue for removal, Pt reports Dominican Plastic surgeon informed her sutures can be removed in 1month, no post op instructions forms at visit.
Pt referred and wound care and 5/28/2021 Pt demographics sent to Morton Plant Hosp, pt. awaiting wound appt.
Test: Anaerobic and Aerobic Culture Report Date: 05/25/2021
Anaerobic Culture Final report
Aerobic Culture Final report Abnormal
Result 1 Comment Abnormal
Result 2 Escherichia coli Abnormal
Antimicrobial Susceptibility Comment
Result 1 Comment
Wound culture +Staph and+ Coli. Pt informed she will need to Complete Doxy and then start Augmentin. Pt currently not on any hormone contraception. Pt denies she is having sexual intercourse and in office urine preg neg.
Exam
Skin:
• Showed erythema large lower abd incision with multiple open areas no drainage, improved since last visit
Umbilicus with multiple suture and right abd with suture x 1 intact edges well approx. right lower abd suture x1 removed, umbilical sutures removed x 2. Remaining 3 sutures with skin growing over suture and unable to remove remaining sutures. ° General appearance was normal.
ASSESSMENT
Open wound of the anterior abdominal wall
PLAN
• Unsp open Wound abd wall, Unsp q w/o penet perit cav, sequela
In House Labs: Pregnancy Test Urine
Amoxicillin-Pot Clavulanate 875-125 MG tablet 1 tab PO twice a day x 10 days. Take with food. START AFTER COMPLETING DOXYCYCLINE., 10 days, 0 refills
Pt informed she need back up birth control method to prevent pregnancy such as condoms
Pt informed she needs to contact surgeon regarding f/U for suture removal instructions, pt approved for wound care which may be able to remove remaining sutrues if surgeon unable to provide further F/U for pt.
complete Doxycycline as prescribed, and THEN start Augmentin
F/U in 2 weeks to re-check wound